RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE: PD-2016-00341 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20040726

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Avenger Crewmember, medically separated for “B12 deficiency” with a disability rating of 10%.

CI  CONTENTION:   The CI  has  made  contention  for  his  mental  health issues.	The complete submission is at Exhibit A.

SCOPE OF REVIEW: The panel’s scope of review is defined in DoDI 6040.44. It is limited to review of disability ratings assigned to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting or non-compensable. Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records. Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation. That role and authority is granted by Congress to the Department  of Veterans Affairs, operating under a different set of laws. The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20040617	VARD - 20040823	
Condition	Code	Rating	Condition	Code	Rating	Exam	

B12 Deficiency with Bilateral Sensory Loss and Paresthesias, with Bilateral Upper Extremity Paresthesias Episodic	

8199-8105	

10%	Peripheral Neuropathy, Left Lower Extremity	8799-8722	10%	20040324	
			Peripheral Neuropathy, Right Lower Extremity	8799-8722	10%	20040324	
			Peripheral Neuropathy, Left Upper Extremity	8799-8722	10%	20040324	
			Peripheral Neuropathy, Right Upper Extremity	8799-8722	10%	20040324	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

B12 Deficiency. According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s symptoms of B12 deficiency condition began in November 2002 when the CI initially developed left lower extremity pain and numbness, and subsequent right lower extremity pain in January 2003.  No diagnosis was made.  In September

2003, the CI was medically evacuated from Kuwait due to the inability to perform the duties of his 16-hour a day traffic checkpoint job. Upon being medically evacuated, he had blood levels drawn, which showed B12 deficiency, and treatment was initiated. His pain and numbness symptoms later included upper extremities.

At the 6 October 2003 neurological consultation examination, 9 months before separation, the CI reported a history of motor vehicle accident with injury to his right hand nerves, chronic difficulty straightening fingers of the right hand, and some chronic sensory deficit in the right hand; however, he denied power difficulties in the arms otherwise. He reported he “hardly” ate during deployment, due to decreased appetite, and had lost 30 pounds, but regained 15 since returning from deployment. Physical examination documented normal functioning of all cranial nerves, normal bulk and tone in all extremities except for mild increase in distal right upper extremity (tone/contracture) likely from the MVA. Motor strength was normal bilateral upper and lower extremities (UE and LE respectively), and there were no abnormal body movements. Sensory examination showed light touch normal in LUE, decreased in the right hand, decreased bilateral LE to around mid-thigh level. Vibration sensation decreased in RUE, normal LUE, and absent in the bilateral LE. Pinprick decreased bilateral LE, and joint position sense normal LUE, absent LLE metatarsophalangeal joint, but present at ankle. The neurologist assessed” bilateral lower extremity sensory loss and paresthesias, with involvement of both small and large fibers (pain/temperature/light touch/vibratory sense) with relative preservation of power in the LE; and bilateral UE paresthesias, episodic.”

During the 21 April 2004 MEB examination (recorded on DD Forms 2807 and 2808) 3 months prior to separation, the CI reported he was diagnosed with B12 deficiency and neuropathy in legs, feet, and lower back, and that he had limitations to lower body movement. The CI also reported problems with his shoulder since shoulder surgery. There was no mention of upper extremity pain related to B12 condition. Physical examination recorded normal upper extremities and abnormal lower extremity, but recorded his condition as: bilateral sensory loss, and B12 deficiency, without specifying the location of the sensory loss.

The 29 April 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of “B12 deficiency with neuropathy.” The CI detailed he would awake with arthritis pain in his legs and a feeling of pins and needles with a “fire” sensation to his feet and ankles. No loss of strength was noted. The CI also reported his arms were falling asleep easily from his shoulder down with returning to normal throughout the course of the day. The review of system documented a history of numbness and tingling in his lower extremities and his arms. Physical examination showed bilateral lower extremity sensory loss and paresthesias, with impairment in sensory perception of pain, temperature, light touch, and vibratory sensory. No other abnormalities noted. The examiner stated, “He (CI) still has residual paresthesias and sensory loss in his lower extremities and his arms.”  Pain was noted as frequent and marked in severity.

At the 1 October 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported he had numbness in both arms at times, and pins and needles sensation at the top of his biceps radiating down the arms. LE issues were not reported. Physical examination showed intact sensation in both UEs. The examiner assessed “peripheral neuropathy of the upper extremities, more likely than not from the B12 deficiency.”

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the condition 10%, coded analogously 8199-8105 (Sydenham’s chorea), rated as mild. The VA rated the conditions of peripheral neuropathy left lower extremity and peripheral neuropathy right lower extremity, 10% each, coded 8799-8722 (analogous to neuralgia). The conditions of right and left upper extremity peripheral neuropathy were added later for additional 10% each rating, coded 8799-8722.

Although the PEB did not state specifically that bilateral lower extremity was included in its rating, the panel agreed that the PEB’s intentions were to include it. The language of “B12 deficiency with bilateral sensory loss and paresthesias” reflected the neurology consultation diagnosis, absent the specifier, “bilateral lower extremity.” Therefore, the panel agreed, the bilateral lower extremity was part of the PEB’s adjudication. The 8105 diagnostic code is not specific to any extremity, i.e., the code reflects a generalized movement disorder. Thus, a rating under this code would include all extremities.

The panel considered the neurological consultation examination, the NARSUM and the C&P examination. Each examination noted the good motor strength, absence of muscle atrophy, and some degree of sensory loss, particularly in the LE with the exception of the C&P examination. The C&P examination documented normal sensory function in the bilateral UE, and the LE was not evaluated. Evidence of gait disturbance, loss of muscle tone, arm or legs giving out, vascular compromise, or loss of reflexes was absent. The panel agreed the evidence supports the 10% rating and no higher for the condition.

The panel adjudged that the upper and lower extremity conditions were an integral component of the B12 deficiency pathology and could not be recommended for additional rating IAW VASRD
4.14 (avoidance of pyramiding). The panel acknowledged the C&P examiner’s assessment of peripheral neuropathy condition in the upper extremities; however, the presence of peripheral neuropathy in any extremity was not diagnosed in the NARSUM or the neurological consultation examination. Therefore, the panel agreed there was insufficient evidence to support a rating under the 8722 code or under any of the peripheral neuropathy code. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the B12 deficiency condition.

BOARD FINDINGS: In the matter of the B12 deficiency condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. The panel, therefore, recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20160401, w/attachments Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015410 , XXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate. I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation. I regret to inform you that your application to the DoD PDBR is denied.

This decision is final. Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,

Enclosure